带有感觉神经重建的股前外侧皮瓣修复舌癌术后缺损的研究

发布时间：2019-05-24 02:13

【摘要】：目的观察应用股前外侧皮瓣修复舌癌切除术后缺损的修复效果,探讨带有神经重建的股前外侧皮瓣与未行神经吻合的股前外侧皮瓣修复舌癌术后缺损,患者语音功能、吞咽功能及再造舌的感觉功能恢复的差异,应用美国华盛顿大学生存质量调查问卷(University of Washington head and neck quality-of-life questionnaire,UW-QOL)评价股前外侧皮瓣修复舌癌术后缺损患者的术后生存质量,比较带有神经重建患者与未行神经吻合患者生存质量的差异。方法共收集52例局部中晚期(T3-4N0-3M0)舌癌患者,将其分为试验组和对照组,于全身麻醉和经鼻气管插管下进行手术。1、舌癌连续整块切除:根据舌癌TNM分期选择不同的颈清扫术,清扫过程中需要保留面动、静脉,甲状腺上动、静脉,对于颈内静脉切除患者则需要将颈外静脉保留以供血管吻合。2、股前外侧肌皮瓣的制备:沿髂前上棘外缘与髌骨外缘做一连线,从该连线中点向腹股沟韧带中点作第二连线,该线相当于旋股外侧动脉的体表投影。根据组织缺损情况及穿支血管情况对皮瓣的大小及厚度进行设计,试验组在皮瓣上保留股外侧皮神经的分支。3、舌与口底缺损重建:在显微镜下根据供区血管蒂与受区血管管径变化,采用端端吻合或端侧吻合将供区血管与受区血管吻合。试验组另行股外侧皮神经与舌神经的吻合。将穿支皮瓣用于舌与口底粘膜及部分面部皮肤缺损的修复,必要时需要折叠皮瓣修复。4、术后皮瓣监测及患者功能检测:术后观察患者皮瓣颜色、是否肿胀、Doppler超声血流探测评估皮瓣血管通畅性,同时观察术后愈合情况。术后6个月检测患者语音功能、吞咽功能,术后3、6个月检测再造舌感觉功能。并采用华盛顿大学生存质量调查问卷(UW-QOL)对两组患者的生存质量进行评价。结果1、52例患者中,试验组25例,行软组织修复及股外侧皮神经与舌神经的吻合;对照组27例,仅行舌癌切除术后软组织的修复。两组患者中51例皮瓣全部成活,皮瓣成活率为98.1%。试验组1例患者皮瓣术后1天发生血管危象,手术探查后恢复血运。术后9天部分皮瓣苍白坏死,部分成活。2例患者术后发生淋巴管漏,经清创缝合术后伤口愈合。其余患者伤口均愈合良好。2、52例患者中10例患者于术后约4个月行放疗。2例患者术后失访,3例患者因肿瘤复发死亡,1例患者原发肿瘤复发。其余46例患者于术后6个月行功能检测,试验组24例,对照组22例。检测结果显示,两组患者语音功能及吞咽功能均恢复较好。试验组患者语音功能评分为4.13±0.68,对照组患者语音功能评分为3.73±0.70,两组患者术后语音功能没有明显差别;试验组患者吞咽功能为5.50±0.51,对照组患者吞咽功能评分为5.10±0.75,试验组患者吞咽功能优于对照组(P=0.04)。对照组仅4例患者测得冷热感觉,试验组21例患者有冷热感知觉;对照组2例患者再造舌有痛觉,试验组20例患者检测到痛觉。术后6个月,对照组患者皮瓣均无两点辨别觉,而试验组患者20例可检测到两点辨别觉(5.15 mm±3.20);并且,随着术后恢复时间的延长,两点辨别能力增强。3、术后6个月对患者生存质量进行评价,结果显示股前外侧皮瓣修复舌癌术后缺损,患者总体生存质量得分为907.39分。其中,得分最高的3个分项目为肩功能、焦虑和疼痛,得分最低的3个分项目为咀嚼、味觉和语言。试验组患者在活力、吞咽、情绪项目得分高于对照组,且试验组患者的生存质量总评分高于对照组患者(t=3.07,P=0.00)。结论股前外侧皮瓣修复局部中晚期舌癌术后缺损,并发症少,皮瓣成活率高,对供区外形及功能的损伤小,修复效果理想,患者的语音功能和吞咽功能均可获得良好的恢复。与常规股前外侧皮瓣修复方法相比,带有感觉神经重建的皮瓣修复局部中晚期舌癌术后缺损,有助于患者吞咽功能的恢复,而对语音功能的恢复无明显影响。并且,带有神经吻合的患者术后感觉功能的恢复优于常规股前外侧皮瓣修复的患者,患者满意度增高,进而提高了患者的生存质量。随着带感觉神经的股前外侧皮瓣临床疗效得到越来越多的肯定,可能将成为股前外侧皮瓣修复舌癌术后缺损的常规术式。
[Abstract]:Objective To observe the effect of the application of the anterolateral skin flap in the repair of the defect after the operation of the tongue cancer, and to investigate the defect of the front lateral skin flap with the nerve reconstruction and the anterolateral skin flap of the non-line nerve to repair the postoperative defect of the tongue cancer and the voice function of the patient. The difference of the sensory function of the swallowing function and the reconstructive tongue was used to evaluate the postoperative quality of life of the patients with the defect of the tongue cancer after using the University of Washington head and neck quality-of-life questionnaire (UW-QOL). To compare the difference of the quality of life between the patients with the neuroreconstruction and the non-linear neuroanastomosis. Methods A total of 52 patients with locally advanced (T3-4N0-3M0) tongue cancer were collected and divided into the test group and the control group. In the patients with internal jugular vein, it is necessary to reserve the external jugular vein for the vascular anastomosis.2. Preparation of the anterolateral myocutaneous flap: make a connection with the outer edge of the patella along the outer edge of the upper spinous process of the patella, and make a second connection from the midpoint of the connecting line to the middle point of the inguinal ligament, This line is equivalent to the body surface projection of the lateral femoral artery. The size and thickness of the skin flap were designed according to the condition of the tissue defect and the condition of the blood vessel, and the branch of the lateral skin nerve of the thigh was retained on the test group. An end-to-end anastomosis or end-to-end anastomosis is used to anastomose the blood supply vessel to the region of the subject. In the test group, the lateral skin nerve was found to be in agreement with the nerve of the tongue. The flaps were used for the repair of the skin defects of the tongue and the submucous membrane of the oral cavity and the part of the facial skin, and the flap was needed to be folded for repair as necessary.4. The flap monitoring and the function test of the patient: the color of the skin flap of the patient was observed after operation, and whether the flap was swollen or not, and the blood vessel patency of the flap was evaluated by Doppler flow detection. The postoperative healing was also observed. The voice function and swallowing function of the patient were detected 6 months after operation, and the reconstructive tongue sensation was detected in 3 and 6 months after operation. The quality of life of the two groups was evaluated by the University of Washington's Quality of Life Questionnaire (UW-QOL). Results: Of the 52 patients,25 of the test group, the repair of the soft tissue and the nerve of the lateral skin and the nerve of the tongue were performed, and in the control group, the soft tissue was repaired only after the operation of the tongue cancer. The survival rate of the flap was 98.1%. One patient with the test group had a blood vessel crisis after 1 day after the operation, and the blood was recovered after the operation. The postoperative 9-day partial flap of the skin flap was pale and necrotic, and some survived. In two cases, the lymphatic leakage occurred after the operation, and the wound was healed after the operation of the debridement and suture. The wound of the remaining patients was well healed. In 2,10 of the 52 patients were treated with radiotherapy for about 4 months after operation.2 patients were lost to follow-up after operation, and 3 of the patients died due to the recurrence of the tumor and 1 case had a recurrence of the primary tumor. The remaining 46 patients were tested in 6 months after operation,24 in the test group and 22 in the control group. The results showed that both the voice function and the swallowing function of the two groups recovered well. The voice function score of the test group was 4.13 and 0.68, and the voice function score of the control group was 3.73 and 0.70, and there was no significant difference in the voice function of the two groups. The swallowing function of the test group was 5.50 and 0.51, and the score of the swallowing function in the control group was 5.10 to 0.75. The swallowing function of the test group was superior to that of the control group (P = 0.04). The cold and hot sensation was found in only 4 patients in the control group, and the cold and hot sensation in 21 patients in the test group was found in the control group, and the pain of pain was detected in 20 patients in the test group. In the 6-month post-operation, the flap of the control group had no two-point discrimination, and 20 of the patients in the trial group were able to detect two-point discrimination (5.15 mm and 3.20); and, with the extension of the post-operative recovery time, the two-point discrimination ability was enhanced.3. The quality of the patient's life was evaluated at 6 months after the operation. The results showed that the total survival quality of the lateral skin flap of the thigh was 907.39. Among them, the three sub-items with the highest score were shoulder function, anxiety and pain, and the lowest score of three sub-items was chewing, taste and language. The scores of life quality of the patients in the test group were higher than that of the control group (t = 3.07, P = 0.00). Conclusion The anterolateral skin flap can be used to repair the postoperative defects of the local and advanced tongue cancer, the complication is little, the survival rate of the skin flap is high, the damage to the shape and function of the donor area is small, the repair effect is ideal, and the voice function and the swallowing function of the patient can be recovered well. Compared with the conventional anterolateral skin flap repair method, the skin flap with the sensory nerve reconstruction is used for repairing the postoperative defect of the local middle and late-stage tongue cancer, which is helpful for the recovery of the swallowing function of the patient, and has no obvious effect on the restoration of the voice function. And the recovery of the sensory function after the operation of the patients with the nerve anastomosis is superior to that of the patients who are repaired by the conventional anterolateral skin flap, and the satisfaction of the patients is increased, and the survival quality of the patients is further improved. As the clinical effect of the anterolateral skin flap with sensory nerve is more and more positive, it is possible to be a conventional method for repairing the postoperative defect of the tongue cancer by the anterolateral skin flap.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R739.86

【参考文献】